Hysterectomy has been a first natural and successful application for robotics in gynecologic and reproductive care, but it is also now clear that robot-assisted laparoscopic myomectomy takes full advantage—even more so—of what robotic technology brings to the table.
Conventional laparoscopic myomectomy has been so challenging that relatively few gynecologic surgeons have been willing and/or able to move away from the traditional open approach for treating symptomatic leiomyomata. Laparotomy thus has remained the standard for myomectomy, leaving many women with a limited number of minimally invasive options if they want to preserve their uterus or fertility, and leaving our health care system shouldering millions of dollars in costs associated with invasive approaches.
It is interesting to note that the total direct cost of treating uterine fibroids in 2000 was estimated at $2.1 billion. Most of the cost, the authors wrote, resulted from inpatient care, particularly hysterectomy (Am. J. Obstet. Gynec. 2006;195:955-64).
With all that robotics offers to us, I believe this is about to change.
The Rationale
Two prospective trials have shown less postoperative morbidity and faster recovery with laparoscopic myomectomy. Yet the endoscopic management of leiomyomata is so technically challenging that the majority of cases are still performed via laparotomy. (Few would challenge the notion, I believe, that it is one of the more challenging procedures in minimally invasive surgery.)
The complexity of dissection and, in particular, the complexity of repair with multilayer-sutured closures present challenges that not only require advanced laparoscopic skills but also are associated with a steep learning curve. These challenges have consistently raised concerns about whether laparoscopy increases conversion rates and whether it can lead to uterine rupture.
There also are longstanding, published limitations placed on the kinds of tumors that can be treated with conventional laparoscopy in order to minimize the risk of conversion to laparotomy. It is often stated that cases involving fibroids greater than or equal to 5 cm, intramural fibroids, an anterior location, and preoperative use of GnRH agonists are too difficult to handle laparoscopically and are likely to increase the conversion rate (Human Reprod. 2001;16:1726-31).
Current robotic technology essentially erases almost all of the limitations of conventional laparoscopy. The features of the technology—improved dexterity and precision of the instruments as well as the three-dimensional imaging—allow the endoscopic approach to be more accurately modeled after (and reflective of) traditional open techniques.
The da Vinci surgical system, which is the only Food and Drug Administration-approved robotic device for use in gynecologic surgery, provides us with a means to overcome the difficulties associated with hysterotomy, enucleation, repair, and extraction that we encounter with the conventional laparoscopic management of fibroids.
The Setup
The da Vinci system comprises a surgeon's console, a vision system that provides three-dimensional imaging through a 12-mm endoscope, and a patientside cart with robotic arms and various EndoWrist instruments.
At the console, the surgeon controls the instruments, the camera, and an energy source, all via a stereoscopic viewer, hand manipulators, and foot pedals. One of the robotic arms holds the endoscope while the other two or three arms hold the instruments.
The instruments come in either 8- or 5-mm sizes and possess 7 degrees of movement, a range that replicates or surpasses the human hand's full range of motion.
Overall, the technique itself for robot-assisted laparoscopic myomectomy does not differ significantly from what is done in conventional laparoscopy, except that the critical steps of hysterotomy, enucleation, and repair are dramatically facilitated while the surgeon adheres to the principles of open surgery.
The bottom line is that robotics affords us the ability to perform the procedure as if it were being done as an open procedure, with the only change being the route of access.
We first place a 12-mm port at or above the umbilicus, depending on the size of the uterus, to accommodate the endoscope and camera arm. As a general rule, I advise leaving at least a handsbreadth distance (approximately 8-10 cm) between the endoscope and the top of an elevated uterus or leiomyoma during bimanual examination, with the patient under anesthesia.
This spacing is important during myomectomy because the enucleation process will result in the leiomyoma projecting out toward the endoscope. By leaving an adequate working space at the beginning, we are able to compensate for a loss of optical working distance and maintain our ability to manipulate our instruments.
We then place an 8-mm port in the left and right lower quadrants, placing them more cephalad and lateral in the case of larger uteri or leiomyomata. These ports will mount directly to the operating robotic arms.